3

2

18 2555 15.30 - 17.00 . Sapphire 4

(.)
2555

19201

(General practitioners)

(Specialists)

(Specialists) (Specialists of subspecialties)

2 3
Dawson Reporta -- (the germ
of primary/secondary/tertiary care distinction)
(Dawson, 1920; Beales,
1980; Egwu, 1984; Grayson and Moss, 1980)
2

(Loux, 1997; Hashem et al., 2003)

(Pelling, 1997)
3


(Maggs, 1993)
(Muecke and Srisuphan, 1989)
1

 4

(Granshaw,1994)

(General Practitioner)
(
)
Scientific doctor

(Shorter, 1993; Gelfand, 1993)
5



(Granshaw, 1994; Rosser,
1996; Friedson, 1970;Pellegrino, 1983;Toop, 1998)

(Full-time
specialism 1910 1960)6
10 (Research seminar)7
(Gelfand, 1993; Granshaw, 1994)

(Toop, 1998)
6
Death the professor of medicine
(General medicine) (Peart, 1970)
7

Balint group (Balint et al., 1993)
4
5

 Balint (The doctor,

his patient and the illness) 1950 1957
(Balint, 1957) 8

() 3
i) ;
ii) ; iii) (
); iv)
; v) ; vi)
; vii) (General
Practitioner) (Specialist)

Balint Research seminar



( )

1957 1963, , 2000, 2002, 2003,


University of Edinburgh, Scotland
19539 (Howie et al., 1986) (Health Centre)
Health Centre ()
Health Centre
(
Health centre )

1965 (Geyman, 1971)

(Gray, 1998)
(Academic discipline) Discipline
Specialty
(
)
Discipline Doctor as well as Philosopher (
) Specialty

(Ben-Zira, 1986)

196610
(General Practice) (Family Practice)
Family Doctor Family Doctors
(
)

Lecture 1935 (Barber, 1952)

The Lancet (Prof. McWinney) (McWinney, 1966)
9

10


(Taylor, 1994; Horder, 1998)
1972 / (
WONCA : 72 ) (Cartwright and Anderson, 1981)
/




11

12 (Modern or Scientific medicine)
(Cosmopolitan medicine)13

World Organisation of National Colleges, Academies and Academic Association of

General Practitioners/Family Phycisians 1998
12
(Holistic) 1926 (Smuts, 1926)
(Entities
are grater than and different from the sum of their parts) J.C. Smuts
( .. 1950) 1960s
() Holistic
(Socrates)
(The part can never be well
unless the whole is well) (Loux, 1997)
13
(Cosmopolitan medicine) (Scientific
medicine) (Western medicine)
(Brieger, 1997)
11



(Technical term)
(Patient-centredness)14
(May and Mead, 1999) (Empathy)
(Squier, 1990) (Black, 2004)

(Cassell, 1982; Levin, 1996)
(Tarrant et al., 2003) (Unique
human being) (Balint, 1969; Balint et al., 1993)
(Byrne and Long,
1976) (McWhinney, 1985)
(Grol et al., 1990; Lipkin, Jr. et al.,
1984; Winefield et al., 1995)
(Henbest and Stewart, 1990; Henbest and Stewart, 1989; Lipkin, Jr. et al.,
1984) (Mead and
Bower, 2000a)

,

, ,
, ,
(Stewart
et al., 1995)

--,

,
, ,
(Mead and Bower, 2000b)

Patient-centreness ( patient-centered care)

technical term
(May and Mead, 1999)
14

10

, ,
,
(Stewart, 2001)

---/
/ ( Existential dimension (WONCA, 2005)
)15 (Astrow et al., 2001; Koenig,
2000; Larimore et al., 2002; Levin, 1996; Levin et al., 1997; Loux, 1997; Shi,
1994; WHO, 2008)
(Integration)
2
i) (
)
(Mercenier, 1992; Unger and Criel, 1995; Van Lerberghe and Lafort, 1990)
ii) () ---
(Polyvalent team)
(Mercenier, 1986; Starfield, 2001)
(Continuity)
--

(Forrest and Starfield,
1998; Freeman and Hjortdahl, 1997)
(Coordination: intra- and inter-sector) (Bodenheimer et al., 1999; Taylor,
Existential dimension Spiritual dimension
...


15

11

1994;WHO, 2008) (Community

involvement and participation) (Morgan, 2001; Raeburn et al., 2006; Zakus
and Lysack, 1998)
(Solidarity) (Lillie-Blanton and Hoffman, 2005; Smith, 1992)
(Equity) (Gwatkin, 2001; Shi et al., 1999)
(Accessibility) (Starfield, 1994)

(de Maeseneer et al., 2008; WHO, 2008)

16
(Drury, 1998; Jefferys, 1998)

(Unger and Criel, 1995)



(Mercenier, 1986;
Pongsupap, 2007)
(Pongsupap et
al., 2006; Pongsupap, 2007; Pongsupap and Van Lerberghe, 2006b; Toop,
1998;Unger et al., 2002; Unger and Criel, 1995)
/

(Patient-centredness) (Grol et al., 1990)

(Henbest and Fehrsen, 1992; Henbest and Stewart,
1990; Henbest and Stewart, 1989; Pongsupap and Van Lerberghe, 2006b; Pongsupap and
Van Lerberghe, 2006a; Unger et al., 2002)
16

12

--


(Luxury care)

(Van
Lerberghe and Lafort, 1990; Donaldson, 1976; Riley, 1977)
()
--


(
)




17 (Riley, 1977; Unger and Criel, 1995)

Rockefeller
3 1) ; 2)

Siam theory and practice of medicine
enveloped in the deep darkness of ignorance and superstition;
craft and deception; destroyers of human life; chains of ignorance and consequent
misery; unnatural, cruel, and destructive custom; diametrically oppose to nature; the most
ludicrous notions; puerility, imbecility, nonsensical; (Bradley, 1865; Riley, 1977)
17

13

; 3) (Pearce, 1922)

(Hongladarom, 1988; Shapiro et al.,
1992; Pongsupap, 2007)

Alma-Ata18 .. 1978 Health for All by the year 2000
Primary Health Care (PHC)
(WHO, 1978)

(Doherty and Govender, 2004)

(de Maeseneer et al., 2008)
(Young, 1983) (Leslie, 1976) Zaire
(Kasongo project team, 1982) (Rakue et al., 1998; Vachrotai,
1976; Vachrotai, 1979)
(Rohde
et al., 2008)
(Favin et al.,
1984; Wibulpolprasert et al., 2008)
Alma Ata Declaration (1978): PHC is essential care based on practical, scientifically sound
and socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at cost that the community can afford to maintain at every stage in a spirit of self reliance and self determination
Basic minimum needs 8 (WHO, 1978)
18

14

 (Primary Health Care)19

(Kawee, 1983; Rakue et al., 1998;
Singhadej et al., 1983)
Alma-Ata
(Egwu, 1984; Muldoon et al., 2006) Primary Care (PC)
(Engstrom et al., 2001; Muldoon et al., 2006; Rethans,
1988) Primary Health Care (PHC) (Egwu,
1984; Favin et al., 1984; Muldoon et al., 2006; Van Balen, 1994; Van Damme
et al., 2002)
PHC
(Doherty and Govender, 2004)

Comprehensive

PHC
(Polyvalent health personnel) (Doherty and
Govender, 2004; Unger and Criel, 1995; Van Damme et al., 2002)

Selective PHC (Vertical

programs) (Boyles, 1998; Cueto, 2004; Walsh and Warren, 1979)

(Rakue et al., 1998; Vachrotai, 1979);

Lysack, 1998)

(Morgan, 2001; Zakus and

( .
800,000 ) ;
; (
); ( HIV/AIDS
prevalence Condom promotion, Prevention of mother-to-child transmission)
(Rohde et al., 2008)
19

15

PHC 20
(Mercenier, 1986;Unger and Criel, 1995)
Harare Declaration21

(Harinasuta, 1973; Rohde et al., 2008)
22
(Piyaratn, 1982; Zimmerman, 1931)

() (Nitayarumphong et al., 2000; Van
Lerberghe and Lafort, 1990)
(Pongsupap, 2007)

----
--
(Local health system) (WHO,
1988)
21
Harare Declaration (1987): A District Health System (DHS) is taken to mean a more or
less self-contained segment of the national health system which comprise a well defined
population living within a clearly defined administrative and geographical area, either rural
or urban, and all institutions and sectors whose activities contribute to improve health
district concept derives from two rationales:... the implementation of the PHC strategy,
requiring a decentralised management, (and) the organisation of integrated health systems
which implies that one single team manages simultaneously the district hospital and the
network of health centres (dispensaries) (WHO, 1987;WHO, 1988)
22
Prof. Zimmerman Rural survey 1930
Rockefeller Foundation

Junior doctor
(Zimmerman, 1931) 1935 Junior sanitarian ()
(Nitayarumphong et al., 2000)
(Pongsupap, 2007)
20

16

 (Chuengsatiansup, 1999)

(Hathirat et al., 2001; Pongsupap, 2007)
(Rawaf et al.,
2008; Williams et al., 2002)
(Pannarunothai
et al., 2000; Pannarunothai and Mills, 1997)

(Rohde et al., 2008)

(Pannarunothai et al., 2004; Towse et al., 2004; WHO, 2008)

(Smith, 1992; WHO, 2008)
World Health Reports
(WHR, 2008; WHR, 2010)
() (Rohde et al., 2008)
(Administrative integration)
(Operational integration)
(Pongsupap, 2007)

2 (WHO, 1987)
(:
Top-down process) (
: Bottom-up process)


(Integrated health care system)

(Unger and Criel, 1995; Van
Lerberghe and Lafort, 1990; Mercenier, 1986)

17

 PHC (
) PC (
)
PHC
PC
(Clinical practice)

(Doherty and
Govender, 2004; Muldoon et al., 2006; Unger et al., 2002)
World Health Report 2008
PHC PC

23 24
PHC 1) Transformation and regulation of existing health systems; aiming for universal access and social health protection;
2) Dealing with the health of everyone in the community; 3) A comprehensive response to
peoples expectations and needs, spanning the range of risks and illnesses; 4) Promotion of
healthier lifestyles and mitigation of the health effects of social and environmental hazards;
5) Teams of health workers facilitating access to and appropriate use of technology and
medicines ; 6) Institutionalized participation of civil society in policy dialogue and accountability mechanisms; 7) Pluralistic health systems operating in a globalized context; 8) Guiding
the growth of resources for health towards universal coverage; 9) Global solidarity and joint
learning; 10) Primary care as coordinator of a comprehensive response at all levels; 11) PHC
is not cheap: it requires considerable investment, but it provides better value for money
than its alternatives (WHO, 2008)
24
1) Extended
access to a basic package of health interventions and essential drugs for the rural poor;
2) Concentration on mother and child health; 3) Focus on a small number of selected
diseases; 4) Improvement of hygiene, water, sanitation and health education at village
level; 5) Simple technology for volunteer, non-professional community health workers; 6)
Participation as the mobilization of local resources and health-centre management through
local health committees; 7) Government-funded and delivered services with a centralized
top-down management; 8) Management of growing scarcity and downsizing; 9) Bilateral aid
and technical assistance; 10) Primary care as the antithesis of the hospital; 11) PHC is cheap
and requires only a modest investment (WHO, 2008)
23

18

 (Shifting of Tasks)

(WHO, 2008)

Dawson

()

Alma-Ata

--


Primary Health Care (PHC)
Primary Care
(PC)
PHC

PC PHC
World Health Report 2008





-

19

--

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